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r, Fi <br />DISCLOSURE OF LOBBYING ACTIVITIES Approveaby OMB <br />Complete this form to disclose lobbying activities pursuant to 31 U.S_C. 1352 0348.00n6 <br />ISee reverse for mihlic hiirdpn Hi-Inc-co <br />0 <br />1. Type of Federal Action: <br />2. Status of Federal Action: <br />3. Report Type: <br />Fla. contract <br />Ela. bid/offer/application <br />Fla. initial filing <br />It. grant <br />Is. initial award <br />b. material change <br />c. cooperative agreement <br />c. post-award <br />For Material Change Only: <br />d. loan <br />year quarter <br />e. loan guarantee <br />date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: <br />- <br />5. If Reporting Entity in No. 4 is Subawardee, Enter Name <br />Prime F <br />]Subawardee <br />and Address of Prime: <br />Tier of known: <br />Congressional District, if known: <br />Congressional District, if known: <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description: <br />CFDA Number, if applicable: <br />6. Federal Action Number, if known: <br />9. Award Amount, if known: <br />S <br />10. a. Name and Address of Lobbying Registrant <br />b. Individuals Performing Services (including address it <br />(if individual, last name, first name, MI). <br />different tram No. 10a) <br />(last name, first name, MI)r <br />11. Information requested through this form is authorized by title 31 <br />U.S.C. section 1352. This disclosure of lobbying activities is a material <br />Signature: <br />representation of fact upon which reliance was placed by the tier <br />above when this transaction was made or entered into. This <br />Print Name: <br />disclosure is required pursuant to 31 ILS.C_ 1352. This information <br />will be reported to the Congress semi-annually and will be <br />Title: <br />available for public inspection. Any person who fails to file the <br />required disclosure shall be subject to a civil penalty of not less <br />Telephone No.: Date: <br />than $10,000 and not more than $100,000 for each such failure. <br />F 2faI U9-B~,Only h. AWt]gld e~ ` fir" { L1^ 7 <br />fx " p <br />7^Wt:f .u. }h + <br />. <br />x r p tom` S <br />4 <br />~ <br />~ <br />~ <br />Aulhonzed for Loral Reproduction <br />s <br />k <br />- <br />~ <br />5 <br />u-3'3'f> <br />rn a+&.t,ASF' 4s+yi.~''i~" y <br />.N ,.:A" <br />;NM <br />y`y-.~ <br />Standard Form LLL (Rev. 7 -9]) <br />jY ..v5,y; F"y -t <br />